Fill and Sign the Subpoena Duces Tecum Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) SUBPOENA FOR DOCUMENTS TO A NON-PARTY TO: ____________ Medical Center ________________________ ________________________ You are hereby commanded to do each of the following acts at the instance of the Defendant, ____________, Inc., within _________ ( ) days after service of this subpoena. That ____________ Medical Center produce and permit the Defendant, ____________, Inc., to inspect and copy each of the following documents: "Any and all medical records, correspondence, notes, memoranda, reports, x-rays or other documents, including an itemized statements of charges, which relate to the treatment and medical condition of ____________ , who resides at - 1 - ____________________________________ , ____________ ; Social Security Number ____________ , injured on the ____ day of _______________, 20____. Such production and inspection is to take place at the place where the documents or things are regularly kept or at some other reasonable place designated by you. You are further advised that other parties to the action in which this subpoena has been issued have the right to be present at the time of such production or inspection. You have the option to deliver or mail legible copies of documents or things to the party causing the issuance of this subpoena but you may condition such activity on your part upon the payment in advance by the party causing the issuance of this subpoena of the reasonable costs of the making of such copies. You have the right to object at any time prior to the date set forth in this subpoena for compliance. Should you choose to object, you should communicate such objection in writing to the party causing the issuance of this subpoena and stating, with respect to any item or category to which objection is made, your reasons for such objection. Signed this ______ day of _________, 2001. ___________________________ CLERK By:_________________________ Deputy Clerk - 2 - RETURN ON SERVICE: By:______________________ Date:____________________ - 3 - CERTIFICATE OF SERVICE I hereby certify that I have on this the ___ day of ___________, 20___, served a copy of the foregoing pleading upon counsel for the Plaintiff as follows: Plaintiff’s Attorney _____________________ Mailing Address _____________________ _____________________ _____________________ _______________ ____________ _____ - 4 - CERTIFICATE I hereby certify that the attached is a true and complete copy of the records pertaining to _________________________________ in my custody, that I am the custodian and keeper of said records. I further certify that said records were made in the regular course of business of ____________________________ and that it was in the regular course of business for such records to be made at the time of the events, transactions or occurrences to which they refer, or within a reasonable time thereafter. Signed this _____ day of _____________________, 2001. _________________________________ CUSTODIAN OF RECORDS SUBSCRIBED AND SWORN TO before me on this the ________ day of ____________________, 20___. ____________________________________ NOTARY PUBLIC - 5 -